Update Health History


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Nokomis Massage & Wellness LLC 5309 Lyndale Ave S Ste 202 Minneapolis, MN 55419 612-767-9084

[email protected]

www.NokomisMassage.com

Massage Therapy Client Information & Waiver/Release Form Client Name______________________________________________ Date of Birth__________ Gender M F Address___________________________________________________________________________________ Street

City

State

Zip

Occupation___________________________________ Employer____________________________________ Phone _________________Email _________________________________ Referred by___________________ Emergency Contact _________________________________________________________________________ Name

Relationship

Phone Number

Massage and General Health Information: Last time you received professional massage/bodywork? _______________ List the reason(s) for your massage visit including symptom(s): (e.g. neck tension, headaches, stress, low back pain) _________________________________________________________________________________________ _________________________________________________________________________________________ How do these symptoms/conditions interfere with your daily living (e.g sleep, work, exercise, home life) _________________________________________________________________________________________ _________________________________________________________________________________________ Are you currently seeing a Chiropractor, Physical Therapist, or Physician for these or other conditions? Y N Please Explain: ____________________________________________________________________________ Have you had a recent major surgical procedure, injury or accident? Y N: _____________________________ What are your expected outcomes or goals for receiving massage:____________________________________ List medication(s) currently taking:_____________________________________________________________ Please circle your stress level: Low 1 2 3 4 5 High Do you wear contacts? Y N Are you allergic to any Lotions or Oils? Y N Can you comfortably lie on your: Stomach Y N Back Y N Are you comfortable with the Massage Therapist working on the following body areas: Head Abdomen

Y N Y N

Neck Chest/Pecs

Y N Y N

Face Y N Hips Y N

Shoulders Y Gluts/Buttock Y

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N N

Back Y N Legs Y N

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Systems Review: Please indicate if any of the following conditions apply: C for Currently and P for Past. (Leave blank if not applicable) Musculo-Skeletal __ Headaches/ Migraines __ Neck pain/stiffness __ Strains/Sprains __ Back, hip pain __ Shoulder, arm, hand pain __ Leg, foot pain __ Chest, ribs, abdominal pain __ Jaw pain/TMJ __ Tendonitis/Bursitis __ Arthritis __ Osteoporosis __ Scoliosis __ Spasms/cramps __ Broken/Fractured bones __ Other:________________ Skin __ Rashes __ Allergies __ Athlete’s foot __ Acne __ Bruise easily __ Hemophilia/Blood thinners

Circulator/Respiratory __ Dizziness __ Shortness of breath __ Fainting __ Stroke __ Heart condition __ Allergies __ Asthma __ High/Low blood pressure __ Other:_________________

Nervous System __ Numbness/tingling __ Fatigue __ Sleep disorders __ Ulcers __ Paralysis __ Herpes/shingles __ Chronic Fatigue Syndrome __ Other:__________________

Digestive __ Reflux __ Constipation __ Intestinal gas/bloating __ Diarrhea __ Irritable bowel syndrome __ Crohn’s Disease __ Colitis __ Other:_____________

Other __ Loss of Appetite __Frequent Colds or Flu __ Depression __ Hearing Impaired __ Difficulty concentrating __ Diabetes __ Fibromyalgia __ Post/Polio Syndrome __ Cancer __ Other:________________

Reproductive System __ Pregnancy

Under certain conditions such as: blood clots, infections, congestive heart failure, contagious diseases pitted edema massage should not be performed, please make sure that you have made the Therapist aware of any of those conditions

Please add any additional significant new health history: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

_____________________________

_________________________________

_______________

_____________________________

_________________________________

_______________

Client Signature

Massage Therapist/Staff Signature

Client Printed Name

Massage Therapist/Staff Printed Name

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Date

Date

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